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Personal Information
*First Name:

*Last Name:
Middle Name:
Present Address Permanent Address
*Phone Number:

Referred By:
Employment Desired
Position     Date you can Start     Salary Desired  
Are you employed? Yes
If so, may we inquire of your current employer? Yes  
Are you under 18 years of age? Yes
If yes, what is your age?    
What is your highest level of education?     When are you available to work?    
Former Employers
Month/Year Name of Employer Salary Position Reason for Leaving
References     Give below the names of 3 persons not related to you, whom you have known at least one year.
Name Address Phone Number Years Known
By submitting this form, I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.
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8 Beach Street, York Beach, ME 03910